Interpersonal Therapy for Depressed Adolescents

Modern life is stressful and leaves its psychological scars on too many adolescents, who are unable to cope effectively, never reach their human potential. An adolescent who says “I’m depressed” or “I’m so down” may be describing a mood that last only a few hours or a much longer lasting mental disorders. The prevalence of adolescent depression in the general population is substantial, ranging from 3% to 9% (Shaffer & Waslick, 2002). Major depression has been associated with impairment in psychosocial functioning at school, with friends and with family.

Depression has been identified also as a leading risk factor for suicidal ideation and attempts and completed suicide (Shaffer, 1996). Studies following depressed adolescents find high rates of recurrence into adulthood (Puig-Antich et al. , 1993). It does not just automatically go away. Rather, adolescents who are diagnosed as having a depression are more likely to experience the problem on a continuing basis in adulthood than are adolescents not diagnosed as having depression (Frank et. al. , 2000).

There are many types of treatment for depressed adolescents including psychodynamic/psychoanalytic psychotherapy, cognitive behavioral therapy, family therapy, group therapy and pharmacotherapy. Many of these treatments are widely used in clinical practice despite the fact that they lack sufficient evidence for their efficacy with adolescents. This paper will analyze the effectiveness of Interpersonal Psychotherapy (IPT). Interpersonal Psychotherapy (IPT) Interpersonal therapy (IPT) was initially developed as a time-limited, focused treatment of depressed non-bipolar adult outpatients.

The main goals of IPT are to decrease depressive symptomotology and to improve interpersonal functioning. IPT assumes that the development of clinical depression occurs in a social and interpersonal context and that the onset, response to treatment and outcomes are influenced by the interpersonal relations between the depressed patient and significant others (Kiesler, 1999). Interpersonal therapy has been studied by two groups in both open and controlled trials for adolescent depression (Mufson et al. , 2004).

Interpersonal therapy was, in one published randomized controlled trial, shown to be superior to a treatment-as-usual control. Clinical depression in the IPT framework is conceptualized as having three components: symptom formation, social functioning and personality. IPT intervenes in the first two processes but it does not purport to have an impact on the enduring aspects of personality (Klerman, 1984). The therapeutic model conceptualizes four specific interpersonal problems: interpersonal disputes, role transitions, grief and interpersonal deficits.

The therapy usually focuses on one of these problem areas. 1. Interpersonal Disputes tend to occur in marital, family, social or work settings. They can be conceptualized as a situation in which the patient and other parties have diverging expectations of a situation and this conflict is severe enough to lead to significant distress. In these circumstances, IPT would aim to define how intractable the dispute was and identify sources of misunderstanding via faulty communication and invalid or unreasonable expectations.

The therapist aims to intervene by communication training, problem solving or other techniques that facilitate change in the situation. 2. Role transitions are situations in which the patient has to adapt to a change in life circumstances. These may be developmental crises, adjustments in work or social settings or adaptations following life events or relationship dissolutions. In those who develop depression, these transitions are experienced as losses and hence contribute to the development of psychopathology.

IPT aims to help the patient with role transition difficulties to reappraise the old and new roles, to identify sources of difficulty in the new role and to develop and implement solutions for these difficulties. Suitable interventions include linking the patients affect to the difficult transition, clarification of the pros and cons of the new situation in comparison to the old, identification of skills needed to feel more confident and successful in the new role, practicing these skills and applying them to their significant relationships.

3. Grief is simply defined in IPT as loss through death. The grieving process can be abnormal by being delayed, distorted or by becoming a chronic reaction. The IPT therapist helps by reconstructing the patient’s relationship with the deceased, helping to address unresolved issues in the relationship, linking the depression to the feelings for the deceased as well as through empathic listening to help facilitate the mourning process.

A primary aim of the grief work is to help the patient to establish new relationships and increase their emotional support system. 4. Interpersonal deficits would be diagnosed when a patient reports impoverished interpersonal relationships in terms of both number and quality of the relationships. In many cases the patient and therapist will need to focus upon both old relationships as well as the relationship with the therapist. In the former, common themes should be identified and linked to current circumstances.

In using the therapeutic relationship, the therapist aims to identify problematic processes occurring such as excessive dependency, fear of intimacy, deficits in initiating or maintaining relationships, or hostility and will aim to modify these within the therapeutic framework as well as by practicing new approaches to developing new relationships. In this way, the therapeutic relationship can serve as a template for further relationships, which the therapist will strive to help the patient create. Clinical research has clearly established the efficacy of IPT for the treatment of depression in adolescents.

IPT has also been adapted for various populations such as the elderly, couples and for various kinds of psychopathological states including bulimia (22) and as an adjunctive treatment for bipolar disorder (Elkin et al. , 1989). IPT in Adolescents (IPT-A) Mufson and colleagues (2004) were the first to adapt IPT for use in adolescents with major depression (IPT-A). IPT-A is a manualized treatment, designed to be used once per week for 12 weeks. The goals of the treatment are to reduce depressive symptoms and to address the interpersonal problems associated with the onset of the depression.

The objectives of treatment take into account the adolescent’s developmental tasks including individuation, establishment of autonomy, development of romantic partners, coping with initial experiences of loss and death and managing peer pressure. IPT-A focuses largely on current interpersonal issues that are likely to be areas of the greatest concerns and importance to adolescents (Mufson, 2004). In addition, Mufson and colleagues (2004) stated that the treatment manual of the therapy is clear and user friendly.

It is organized as a step-by-step description of the therapeutic tasks of treatment and includes clinical vignettes to help guide the reader in the implementation of IPT-A. The manual also provides a brief overview of adolescent depression (including diagnosis, assessment, clinical course and other treatments) and efficacy data from clinical trials conducted using IPT-A. The manual has a section on special issues that arise when working with adolescents and how they can be addressed while staying within the IPT-A treatment framework.

Modification for Adolescents The IPT-A differs from the adult version due to three major modifications: shortening of treatment duration from 16-20 weeks to 12 weeks of individual psychotherapy, adding the involvement of parents and the reconceptualization of the sick role to have a more limited focus. The involvement of parents is throughout the therapy process. During the initial phase of treatment, the parents receive psychoeducation about depression, the limited sick role and treatment procedures.

The adolescents and their parents are informed that the teenager has an illness that may affect his/her school performance and normal activities, but the adolescent is encouraged to participate in as many of his normal activities as possible. The parents are advised to encourage this participation and are informed that the teenager’s performance (i. e. , grades, cleanliness of room, completion of chores) will improve as the adolescent begins to feel less depressed. The teenager is discouraged from falling prey to the temptation to stay in bed, arrive at school late, cut classes, skip homework, and withdraw from activities with peers.

The therapist emphasizes the need for familial support for the teen’s treatment. During the sessions, family members are asked to participate in the middle phase of treatment as needed to facilitate work on communication between the adolescent and family members that has been identified as a problem area. In the termination phase of the treatment, a family member is included in a session to discuss progress in treatment, changes in the family as a result of the treatment and the need for further treatment. Phases of the Treatment The treatment is divided into three phases: initial phase, middle phase and termination phase.

The initial phase focuses on depression diagnosis, psychoeducation about the illness and limited sick role, exploration of the patient’s significant interpersonal relations, and the identification of the problem area that will be the focus of the entire treatment. In the initial phase, the therapist conducts the “Interpersonal Inventory,” which is a detailed review of the patient’s significant relationships, both current and past. Examples of questions from the inventory are: • Who in your family do you feel you confide in and go to help for?

• What are the positive and negative aspects of your relationship with X? • Are there things you would like to change about this relationship? • Was there a time when you felt differently about your relationship with X? This inventory is the focus of the initial phase of treatment as it provides the necessary interpersonal data to select one of the four problem areas for focus in the middle phase. To conduct the Interpersonal Inventory, it is helpful for the therapist to use the “Closeness Circle” (Mufson, 2004). This is a series of circles, one within the other with an?

in the center, which represents the patient. The goal is to place the adolescent’s significant relationships within the appropriate circles of closeness/importance in the teenager’s life. The result is a picture of the significant people orbiting the adolescent’s life and the emotional valence associated with their position in the adolescent’s life. As in the adult version of IPT, there are four identified problem areas in IPT-A upon which the therapy can be focused: 1. Grief due to death; 2. Interpersonal disputes with friends, teachers, parents and siblings; 3. Role transitions such as changing schools (e. g.

, elementary to junior high or junior high to high school), entering puberty, becoming sexually active, birth of another sibling, becoming a parent, parental divorce, illness of a parent; and/or 4. Interpersonal deficits such as difficulty in initiating and maintaining relationships and communicating about feelings. When there seems to be two problem areas, the manual suggests identifying a primary and possibly a secondary problem area. During the middle phase of the treatment, the therapist teaches the adolescent specific strategies that can help him deal with his interpersonal difficulties within one or two problem areas.

The IPT- As techniques include exploratory techniques, encouragement of affect, communication analysis, behavior change techniques, (including decision analysis and role plays), use of the therapeutic relationship and adjunctive techniques. The termination phase includes clarification of the adolescent’s warning symptoms of future depressive episodes, identification of successful strategies that were used in the therapy, generalization of skills to future situations, emphasis on mastery of new interpersonal skills and discussion of the need for further treatment.

In the termination phase, the therapist should encourage the adolescent to identify specific future situations that are anticipated to be difficult or stressful and review the use of the new skills in these situations. This may help reduce relapse and reoccurrence, which are not rare in adolescent depression (Lewinsohn et al, 1994). Therapeutic Techniques According to Weissman et. al (2000), the therapeutic techniques are the follwing: 1. Exploratory techniques include both directive and non-directive techniques.

Directive exploratory techniques include targeted questioning and interviewing. The non-directive techniques include supportive acknowledgment, extension of the topic being discussed by the patient and receptive silence. 2. Encouragement of affect includes facilitating acceptance of painful affect about events or issues; helping the patient use his/her affective experiences in making interpersonal change; and encouraging the development of new, desirable affects that may facilitate growth and change 3.

The communication analysis involves performing a thorough investigation of a specific dialogue or argument that occurred between a patient and another person. Communication analysis identifies ways in which the patient’s communication is ineffective and fails to achieve the goal of the communication. The target is to teach the patient to communicate in a more effective manner by increasing his clarity and directness. 4. Directive techniques for behavior change include educating, advising, limit setting and modeling.

Decision analysis is employed by the therapist helping the patient consider a range of alternative actions that he can take and the possible consequences associated with each of those actions. In role-playing, the therapist and patient act out the skills that the patient is learning in the treatment in a non-threatening way. The therapist can model many useful interpersonal skills such as: affective expression, effective communication and decision-making strategies. The therapist has to select a relevant topic with a manageable task and is encouraged to make it as engaging and fun as possible.

5. The therapeutic relationship in IPT-A provides an example of the patients’ relationships and a forum in which skills can be practiced and feedback can be given. Negative feelings are understood as transference phenomena but are not dealt with using a psychodynamic perspective 6. Adjunctive techniques include work assignments to be done at home between the sessions. The assignments usually involve practicing specific skills that were the focus of the sessions. They are referred to with the adolescents as “interpersonal experiments” or “work at home”.

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